Cardiothoracic Critical Care a, b c Kevin W. Lobdell, MD *, Douglas W. Haden, MD , Kshitij P. Mistry, MD KEYWORDS Critical care Cardiothoracic surgery Quality Safety Value KEY POINTS High-value cardiothoracic critical care (CCC) is rapidly evolving to meet the demands of increased patient acuity and to incorporate advances in technology. The high-performing CCC system and culture should aim to learn quickly and continu- ously improve. CCC demands a proactive, interactive, precise, and expert team, as well as continuity. CARDIOTHORACIC DISEASE AND THERAPY Incidence and Prevalence Acquired heart disease is the leading cause of death in the United States, with 611,106 deaths forecasted for 2016; it affects 11.5% of the population and is estimated to result in 3.7 million hospitalizations annually with an average stay of 4.6 days.1 Approx- imately 152,000 coronary artery bypass (CAB) operations were recorded in the Society of Thoracic Surgeons-Adult Cardiac Database (STS-ACSD) in 2015, while approxi- mately 600,000 cardiac surgical procedures were expected to be performed in 2016.2 Congenital heart disease affects approximately 40,000 children annually in the United States, and 25% of those require surgery in their first year of life.3 8.5% of adults will have a diagnosis of cancer in their lifetime, and cancer was fore- casted to claim 584,881 lives in 2016 (the second most common cause of death in the United States).4 Furthermore, the American Cancer Society estimated 224,390 new cases of lung cancer in the United States for 2016 and 158,080 deaths (which ac- counts for approximately 25% of cancer deaths).5,6 The American Cancer Society also forecasted 16,910 new cases and 15,690 deaths from esophageal cancer in the United States for 2016 (approximately 20% of patients survive 5 years or more after diagnosis, a four-fold improvement over the last 40 years).7,8 The authors have nothing to disclose. a Sanger Heart and Vascular Institute, Carolinas HealthCare System, PO Box 32861, Charlotte, NC 28232, USA; b Carolinas HealthCare System, PO Box 32861, Charlotte, NC 28232, USA; c Cardiovascular Critical Care, Boston Children’s Hospital, Boston, MA, USA * Corrresponding author. E-mail address: [email protected] Surg Clin N Am 97 (2017) 811–834 http://dx.doi.org/10.1016/j.suc.2017.03.001 surgical.theclinics.com 0039-6109/17/ª 2017 Elsevier Inc. All rights reserved. 812 Lobdell et al Procedural Risk CAB surgery, which accounts for 53% of acquired cardiac surgical procedures recorded in the STS-ACSD, has an average operative mortality of 2.2% and mortality and/or major morbidity in 12.3%. Major and minor complications occur in 37.5% of patients; median intensive care unit (ICU) length of stay (LOS) is 47.4 hours, with a mean of 70.9 hours. To- tal LOS is 8.0 days (median) and 9.3 days (mean), readmission to ICU 2.8% and 30-day readmission 10%.9 More specifically, the average incidence of major morbidities and hospital acquired infection (HAI) includes stroke 1.3%, reoperation 3.5%, prolonged ventilation 8.2%, acute renal failure 2.1%, deep sternal wound infection 0.3%, pneu- monia 2.5%, and septicemia 0.9%. Common process metrics include early extubation 49.4% (<6 hours with median initial ventilation 3.6 hours and mean 6.0 hours), reintuba- tion 3.6%, and blood product transfusions 43%.9 Logically, increased complexity of pa- tient or associated procedures correlates with greater mortality, morbidity, and resource consumption. For example, left ventricular assist device implantation has been reported to have 13.2% postoperative mortality,10 while repair of type A aortic dissection has ranged from 12% to 24%.11 The 2015, STS-CCSD report recorded 52,224 operations in the most recent 4-year period with an overall mortality of 3.7% (neonatal 5 10.1%, infant 5 3.0%, chil- dren 5 0.9%, and adults 5 1.7%), which increases to 16.8% for the most complex procedures (STAT Category 5). The STS-GTSD relates a 1.3% mortality and 9.4% major morbidity for pulmonary lobectomy, 5.0% mortality and 16.0% major morbidity for pneumonectomy, and a 3.4% mortality and 33.1% major morbidity for esophagectomy.12 Procedure and Complication Costs Cardiac and thoracic surgery are costly and contribute substantially to a hospital’s in- come and profit margin.13,14 CAB averages $73,420 in the United States,15 while the total cost of lobectomy is estimated at $39,412,16 and esophagectomy charges aver- aged $120,000 to 140,000.17 Hospital costs for the congenital cardiac disease popu- lation are estimated at $1.9 billion.3 Additionally, recent estimates suggest approximately 13.4% of hospital costs, 4.1% of national health expenditures, and 0.66% of the gross domestic product are attributable to critical care.18 The additive costs of complications are considerable, and recent estimates for CAB range from $62,773 for mediastinitis (240% greater costs than without this complica- tion), $49,128 with renal failure, $40,704 with prolonged ventilation, $34,144 with post- operative stroke, $20,000 for reoperation for hemorrhage, to $2744 for atrial fibrillation.19 The CAB average LOS of 7.4 days was also significantly impacted by complications (ranging from 37.8 days for mediastinitis to 9.6 days for isolated atrial fibrillation). HAIs are estimated to cost the United States $35 to 45 billion per year and are common in crit- ical care. The clinical impact of HAIs is also enormous, since HAIs are associated with approximately 6% mortality and 17 extra days of hospitalization.20 Improvement must include the integration of innovative tactics to mitigate the risk of HAI (eg, bioburden reduction through ultraviolet light and copper-impregnated composites).21 Axiomati- cally, multiple investigations corroborate the strong correlation between poor quality and increased cost.22,23 HIGH-VALUE CARDIOTHORACIC CRITICAL CARE High-value cardiothoracic critical care (CCC) must measure and manage the domains of quality (Q), safety (S), value (V), and the resources (R) applied to these efforts (V a [Q 1 S]/R). Global waste in health care is estimated to be approximately $4.3 trillion Cardiothoracic Critical Care 813 annually.24 In the United States, health care consumes approximately 18% of the gross domestic product and 32% of health care expenditures are associated with hospitals.25,26 Recently, in order to improve value and sustainability, the Center for Medicare and Medicaid Services (CMS) has proposed bundled payment models for CAB where the hospital would be accountable for the cost and quality of care during the inpatient stay and for 90 days after discharge.27 This value-oriented payment scheme is significant, since the current reimbursement system may actually benefit hospitals with increased rate of complications. Patient-reported outcome measures are increasing and must be incorporated into the assessment of quality and value. Quality and the High-Performance Organization High-performance organizations (HPOs) are marked by common aspirational goals, alignment, adaptability, and accountability.28,29 The HPO has an action bias and a strong focus on what it intends to achieve. Safety and the High-Reliability Organization High-reliability organizations (HROs) are characterized by their reluctance to simplify, a sensitivity to operations, a commitment to resilience, and their deference to expertise.30,31 HROs have a firm focus on failure—and what they do not want to happen—which requires leadership commitment, a culture of safety, and effective utilization of performance improvement tools. Patient safety and the associated culture of safety are built on a foun- dation of trust,32,33 transparency, and continuous improvement. The Joint Commission popularized “robust process improvement” (RPI), which is comprised of lean methodol- ogies (which focus on elimination of waste), six-sigma (also focused on eliminating waste, but includes statistical methodology to reduce defects to nearly zero), and change management.30 CARDIOTHORACIC CRITICAL CARE STRUCTURE AND PROCESSES Multidisciplinary Team Care The focus factory approach can improve the core competencies and value proposition of a cardiovascular and thoracic service line.34 CCC has been delivered successfully with many different models. The traditional model of cardiothoracic surgeon and/or cardiothoracic surgery residents leading CCC has been challenged by many factors, which include the limitation of resident work hours, complexity of care, and credential- ing.35–38 Currently, many high-performing cardiovascular efforts, including CCC, are multidisciplinary and include various combinations of surgeon, cardiologist, anesthe- siologist, intensivist, advanced care practitioners (nurse practitioners and physician assistants), nurses, respiratory therapists, pharmacists, nutritionists, physical thera- pists, clinical care managers, among others.39,40 These high-performance CCC teams must be proactive, interactive, precise, expert, and provide continuity.41–43 Teaming is increasingly utilized in other industries and vital to the delivery of complex, high-value CCC.44 Additionally, efforts such as TeamSTEPPS highlight the importance of effec- tive team leadership and team training.45,46 Activity-based staffing has been studied for decades, and the concept of optimizing staffing for complexity is central to high-value CCC.47,48 The authors utilize a complexity scoring methodology to quantify demands and match with resources (limiting their advanced care practitioner’s (ACP’s) workload to a total of 15 points) (Table 1).